Marcie Gawel

In situ pediatric trauma simulation: assessing the impact and feasibility of an interdisciplinary pediatric in situ trauma care quality improvement simulation program.

Objective This study aimed to evaluate the feasibility and measure the impact of an in situ interdisciplinary pediatric trauma quality improvement simulation program. Methods Twenty-two monthly simulations were conducted in a tertiary care pediatric emergency department with the aim of improving the quality of pediatric trauma (February 2010 to November 2012). Each session included 20 minutes of simulated patient care, followed by 30 minutes of debriefing that focused on teamwork, communication, and the identification of gaps in care. A single rater scored the performance of the team in real time using a validated assessment instrument for 6 subcomponents of care (teamwork, airway, intubation, breathing, circulation, and disability). Participants completed a survey and written feedback forms. Results A trend analysis of the 22 simulations found statistically significant positive trends for overall performance, teamwork, and intubation subcomponents; the strength of the upward trend was the strongest for the teamwork (&tgr; = 0.512), followed by overall performance (&tgr; = 0.488) and intubation (&tgr; = 0.433). Two hundred fifty-one of 398 participants completed the participant feedback form (response rate, 63%), reporting that debriefing was the most valuable aspect of the simulation. Conclusions An in situ interdisciplinary pediatric trauma simulation quality improvement program resulted in improved validated trauma simulation assessment scores for overall performance, teamwork, and intubation. Participants reported high levels of satisfaction with the program, and debriefing was reported as the most valuable component of the program.

Differences in the Quality of Pediatric Resuscitative Care Across a Spectrum of Emergency Departments

Importance The quality of pediatric resuscitative care delivered across the spectrum of emergency departments (EDs) in the United States is poorly described. In a recent study, more than 4000 EDs completed the Pediatric Readiness Survey (PRS); however, the correlation of PRS scores with the quality of simulated or real patient care has not been described. Objective To measure and compare the quality of resuscitative care delivered to simulated pediatric patients across a spectrum of EDs and to examine the correlation of PRS scores with quality measures. Design, Setting, and Participants This prospective multicenter cohort study evaluated 58 interprofessional teams in their native pediatric or general ED resuscitation bays caring for a series of 3 simulated critically ill patients (sepsis, seizure, and cardiac arrest). Main Outcomes and Measures A composite quality score (CQS) was measured as the sum of 4 domains: (1) adherence to sepsis guidelines, (2) adherence to cardiac arrest guidelines, (3) performance on seizure resuscitation, and (4) teamwork. Pediatric Readiness Survey scores and health care professional demographics were collected as independent data. Correlations were explored between CQS and individual domain scores with PRS. Results Overall, 58 teams from 30 hospitals participated (8 pediatric EDs [PEDs], 22 general EDs [GEDs]). The mean CQS was 71 (95% CI, 68-75); PEDs had a higher mean CQS (82; 95% CI, 79-85) vs GEDs (66; 95% CI, 63-69) and outperformed GEDs in all domains. However, when using generalized estimating equations to estimate CQS controlling for clustering of the data, PED status did not explain a higher CQS (β = 4.28; 95% CI, -4.58 to 13.13) while the log of pediatric patient volume did explain a higher CQS (β = 9.57; 95% CI, 2.64-16.49). The correlation of CQS to PRS was moderate (r = 0.51; P < .001). The correlation was weak for cardiac arrest (r = 0.24; P = .07), weak for sepsis (ρ = 0.45; P < .001) and seizure (ρ = 0.43; P = .001), and strong for teamwork (ρ = 0.71; P < .001). Conclusions and Relevance This multicenter study noted significant differences in the quality of simulated pediatric resuscitative care across a spectrum of EDs. The CQS was higher in PEDs compared with GEDs. However, when controlling for pediatric patient volume and other variables in a multivariable model, PED status does not explain a higher CQS while pediatric patient volume does. The correlation of the PRS was moderate for simulation-based measures of quality.

Disparities in Adherence to Pediatric Sepsis Guidelines across a Spectrum of Emergency Departments: A Multicenter, Cross-Sectional Observational In Situ Simulation Study

BACKGROUND Each year in the United States, 72,000 pediatric patients develop septic shock, at a cost of

Barriers and facilitators to recognition and reporting of child abuse by prehospital providers

4.8 billion. Adherence to practice guidelines can significantly reduce mortality; however, few methods to compare performance across a spectrum of emergency departments (EDs) have been described. OBJECTIVES We employed standardized, in situ simulations to measure and compare adherence to pediatric sepsis guidelines across a spectrum of EDs. We hypothesized that pediatric EDs (PEDs) would have greater adherence to the guidelines than general EDs (GEDs). We also explored factors associated with improved performance. METHODS This multi-center observational study examined in situ teams caring for a simulated infant in septic shock. The primary outcome was overall adherence to the pediatric sepsis guideline as measured by six subcomponent metrics. Characteristics of teams were compared using multivariable logistic regression to describe factors associated with improved performance. RESULTS We enrolled 47 interprofessional teams from 24 EDs. Overall, 21/47 teams adhered to all six sepsis metrics (45%). PEDs adhered to all six metrics more than GEDs (93% vs. 22%; difference 71%, 95% confidence interval [CI] 43-84). Adherent teams had significantly higher Emergency Medical Services for Children readiness scores, MD composition of physicians to total team members, teamwork scores, provider perceptions of pediatric preparedness, and provider perceptions of sepsis preparedness. In a multivariable regression model, only greater composite team experience had greater adjusted odds of achieving an adherent sepsis score (adjusted odds ratio 1.38, 95% CI 1.01-1.88). CONCLUSIONS Using standardized in situ scenarios, we revealed high variability in adherence to the pediatric sepsis guideline across a spectrum of EDs. PEDs demonstrated greater adherence to the guideline than GEDs; however, in adjusted analysis, only composite team experience level of the providers was associated with improved guideline adherence.

Comparing practice patterns between pediatric and general emergency medicine physicians: A scoping review

Abstract Background: Prehospital care providers are in a unique position to provide initial unadulterated information about the scene where a child is abusively injured or neglected. However, they receive minimal training with respect to detection of Child Abuse and Neglect (CAN) and make few reports of suspected CAN to child protective services. Aims: To explore barriers and facilitators to the recognition and reporting of CAN by prehospital care providers. Design/Methods: Twenty-eight prehospital care providers participated in a simulated case of infant abusive head trauma prior to participating in one-on-one semi-structured qualitative debriefs. Researchers independently coded transcripts from the debriefing and then collectively refined codes and created themes. Data collection and analysis continued past the point of thematic saturation. Results: Providers described 3 key tasks when caring for a patient thought to be maltreated: (1) Medically managing the patient, which included assessment of the patients airway, breathing, and circulation and management of the chief complaint, followed by evaluation for CAN; (2) Evaluating the scene and family interactions for signs suggestive of CAN, which included gathering information on the presence of elicit substances and observing how the child behaves in the presence of caregivers; and (3) Creating a safety plan, which included, calling police for support, avoiding confrontation with the caregivers and sharing suspicion of CAN with hospital providers and child protective services. Reported barriers to recognizing CAN included discomfort with pediatric patients; uncertainty related to CAN (accepting parental story about alternative diagnosis and difficulty distinguishing between accidental and intentional injuries); a focus on the chief complaint; and limited opportunity for evaluation. Barriers to reporting included fear of being wrong; fear of caregiver reactions; and working in a fast-paced setting. In contrast, facilitators to reporting included understanding of the mandated reporter role; sharing thought processes with peers; and supervisor support. Conclusions: Prehospital care providers have a unique vantage point in detecting CAN, but limited resources and knowledge related to this topic. Focused education on recognition of signs of physical abuse; increased training on scene safety; real-time decision support; and increased follow-up related to cases of CAN may improve their detection of CAN.

1209: SAFETY THREATS RELATED TO DEXTROSE ADMINISTRATION IN A SIMULATED PEDIATRIC PATIENT WITH SEIZURE

Objective Acutely ill infants and children presenting to the emergency department are treated by either physicians with pediatric emergency medicine (PEM) training or physicians without PEM training, a good proportion of which are general emergency medicine–trained physicians (GEDPs). This scoping review identified published literature comparing the care provided to infants and children (⩽21 years of age) by PEM-trained physicians to that provided by GEDPs. Methods The search was conducted in 2 main steps as follows: (1) initial literature search to identify available literature with evolving feedback from the group while simultaneously deciding search concepts as well as inclusion and exclusion criteria and (2) modification of search concepts and conduction of search using finalized concepts as well as review and selection of articles for final analysis using set inclusion criteria. Each study was independently assessed by 2 reviewers for eligibility and quality. Data were independently abstracted by reviewers, and authors were contacted for missing data. Results Our search yielded 3137 titles and abstracts. Twenty articles reporting 19 studies were included in the final analysis. The studies were grouped under type of care, diagnostic studies, medication administration, and process of care. The studies addressed differences in the management of fever, croup, bronchiolitis, asthma, urticaria, febrile seizures, and diabetic ketoacidosis. Conclusions This review highlights the lack of robust studies and heterogeneity of literature comparing practice patterns of PEM-trained physicians with GEDPs. We have outlined a systematic approach to reviewing a body of literature for topics that lack clear terms of comparison across studies.

Barriers and Facilitators to Detecting Child Abuse and Neglect in General Emergency Departments.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) (32% vs. 0%, p=0.001), walking inside room (30% vs. 0%, p=0.001), and OT activities (writing, 80% vs. 38%, p=0.001). The recall of actual PT activities was similar between CAM-ICU positive and negative patients (>50% match, 27% vs. 38%, p=0.44), whereas CAM-ICU positive patients recalled less OT activities (>50% match, 19% vs. 52%, p=0.01). Conclusions: CAM-ICU positive MV patients have worse PT and OT performances and less recall of their activities during EM. Delirium in MV ICU patients is associated with worse level of activities and memory impairment. Tailoring EM sessions for CAM-ICU positive patients is needed to improve both physical and memory activities.